Transcript INTRODUCTORY TRAINING

Health Care Financing for
Transition Aged Youth
Thursday, November 17, 2005
Children’s Hospital of Wisconsin
Bobby Peterson
Attorney & Executive Director
ABC for Health, Inc.
ABC FOR HEALTH, INC.
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A Wisconsin-based nonprofit public interest
law firm dedicated to linking children and
families, particularly those with special health
care needs, to health care benefits and
services.
ABC FOR HEALTH’S MISSION
ABC for Health’s mission is to provide
information, advocacy tools, legal services
and expert support needed to obtain,
maintain, and finance health care coverage
and services.
WHY A LAW FIRM?
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Families have problems accessing and
financing health care
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Complicated public benefits program
Limited insurance coverage
Lack of understanding and accessible information
Lack of assistance and support in using the
system based on laws and regulation
THE ROLE OF LAWYERS
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Demand letters, including threats of litigation
Represent the family at hearings (e.g.
grievance, appeal, medical review)
Medicaid disputes are handled by the
Wisconsin Department of Hearings and
Appeals – administrative law
HEALTH BENEFITS COUNSELING
A BRIEF HISTORY:
WHAT IS IT AND WHY
DO WE DO IT?
Deciding what the Challenge is
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The many faces of the health care consumer:
What does the client need funding for?
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Unpaid medical bills, secure future medical care,
pay for Rx.
Health Benefits Counseling
- What Is It?
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HBCs provide families the in-depth
counseling, strategizing, and advocacy
assistance they need to ensure the best
chance for eligibility for a variety of public
and private health care financing programs
HBC (continued)
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Case-by-case counseling and advocacy
Focused on health care financing issues
Comprehensive in the areas of:
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Private Health Insurance
Medicaid
BadgerCare
Medical debt payment problems and
collection actions
Health Benefits Counseling
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Computerized eligibility systems make errors
Computerized notices are difficult to read and
understand
“Cascade” of eligibility for all programs
Families often assume they won’t be eligible, or are
unprepared for the application process
Access to legal assistance/consultation is important
Why do families need help with
eligibility?
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Rules are complex and not readily available
to the consumer
Medical care providers often do not have
time or knowledge of programs
Families are already under stress
Assigned county case worker may be
unresponsive to family’s needs
Private insurance, public benefits,
and transition to adult services
Developing a health care
coverage plan
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Start early!
Prepare before your child turns 18 years of
age
ABC for Health’s Health Coverage Plan
offers a concise record of:
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the client’s key health care or coverage issues
ABC for Health staff’s analysis of health care
coverage options and considerations
Coverage Plans
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ABC for Health staff’s services and activity on behalf of the
client
Follow-up and next steps
Important dates and deadlines
Referrals to other health care coverage or financing
resources
ABC for Health’s Health Coverage Plan provides an
essential tool for managing the client’s personal health
information, guiding the client and the provider to
appropriate public and private health care coverage
resources.
Private Insurance Issues
Know your policy
 Parents with plans regulated by Wisconsin Law may
carry an adult child with a disability on their private
insurance
 Hospital or medical expense policies that cover
dependent children may end coverage when the child
reaches maturity. However, coverage of a dependent
child cannot end while the child continues to be both:
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Coverage under Parent’s policy Con’t
Incapable of self-sustaining employment because
of a mental retardation or physical handicap; and
Chiefly dependent upon the person insured under
the policy for support and maintenance.
This applies both to group and individual policies.
Insurers can require notice of continued dependence
after a child reaches the maximum age under the
policy. [s. 632.88, Wis. Stat.]
Typical Health Insurance Problems
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The insurance policy is a contract
Confusing or ambiguous language should be strictly
interpreted in favor of the insured
The reasonable expectations of the insured should
be met
Exclusions must be clear and understandable
Get a specific reason for the denial
Go up the management ladder
Advocacy Strategies
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Common Claim Denials
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Rehabilitative & educational exclusions
Experimental treatments
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Obtain a written definition of experimental treatment
from your policy or insurance company
Obtain supporting literature from your physician (letters,
articles etc.)
Advocacy Strategies (continued)
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Medically Necessary
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How is the term defined in the contract?
Obtain documentation of the need for the service
Is the denial contradicted elsewhere in the policy?
Phantom Clauses
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These may be inserted in a policy without a definition or
without any accurate meaning. For example the phrase
“services, care, or supplies that are not medically
recognized by the American Medical Association.”
Advocacy Strategies (continued)
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Timely payments of claims
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Sec. 628.46 Wis. Stats
“A claim shall be overdue if not paid within 30 days after the
insurer is provided written notice of the fact of a covered
loss.”
Interest of 12% per year
Avoid problems by building a paper trail
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Keep complete records of phone contacts, procedures
approved, names and titles of people to whom you speak
Follow up in writing
Keep contact notes and a file
Overview of Blanket Coverage
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Use Medicaid as back-up to your private
insurance
Medicaid Deductible
Family Fiscal Unit
Use Katie Beckett as a back up for SSI
Public Insurance for Disabled Young
Adults
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Entry points into Medicaid
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BadgerCare
Family Medicaid
Medicaid (deductible
Healthy Start
SSI
Social Security Disability
EPSDT (for children up to age
21)
MAPP
Medicaid through AFDC
CIP and COP
QMB, SLMB
HIRSP
Family Fiscal Unit
(For Family Medicaid)
Fiscal Group Test
All household income and assets added together and
compared to a group eligibility standard.
Family Fiscal Unit (FFU)
Individual income and asset test
FFU Cases
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Circumstances in which the FFU may be
applied include:
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Pregnant Woman
Step Parent
Non-marital co-parents
Child with own income or assets
Non-legally Responsible Relative (NLRR)
FFU may be used to access Medicaid
through Healthy Start, but only until the child
turns 19 or in the case of a pregnant woman.
FFU (Continued)
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When using the Fiscal Test Group standard it is
possible to inappropriately apply income and assets
of one person to another person. That person may
not be legally responsible for the person to whom the
resources are allocated.
Example: in a blended family, the income of the stepparent should not be allocated to the child of the
other parent because the step-parent is not legally
responsible for that child.
FFU (continued)
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Example of some quirks of FFU:
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Do not pro-rate or allocate SSI income
Child support is allocated to the child, not to the
mother
First $50 of child support is disregarded
BADGERCARE
BadgerCare (continued)
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Full Medicaid coverage
Application is at the County Department of Social
Services. “Simplified” application available.
Youth with disabilities are judged on their own
income at age 18 and are eligible until they turn 19.
BadgerCare is available to adults age 19 and older if
they have children and meet the other requirements.
BadgerCare (continued)
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Coverage starts on the first day of the month of
application
Coverage of families with children under the age of
19
Covers both children and parents in the household
Children must live with their parents to qualify(some
foster placements still qualify)
BadgerCare (continued)
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Referral to the child support office may be
involved for single parents seeking
BadgerCare for themselves
Parents receiving Medicare are eligible
Self employment income includes business
asset depreciation
BadgerCare (continued)
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Families with employer sponsored group health
insurance are not eligible if employer pays at least
80% of the cost of family coverage
Must be without insurance for 3 months prior to
application - includes self employed, or individual
plan
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Recent program changes in eligibility
Private insurance complicates eligibility issues
BadgerCare (continued)
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BadgerCare extends Medicaid coverage to:
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Children ages 6 -18 with family income between
100% & 185% FPL
Parents in families with income over AFDC limits
up to 185% FPL
Once enrolled, families may remain in
BadgerCare until income exceeds 200% FPL
Employment and income verification issues
BadgerCare (continued)
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Families with income in excess of 150% of FPL must
pay a monthly premium of no more than 5% of family
income
Premiums can be paid through wage withholding by
employer or through an automated payment system
If a family fails to pay the premium and no good
cause exists, can’t re-enroll for 6 months.
BadgerCare (continued)
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No backdate period
No asset test
No deductible or FFU feature
Providers who accept WI Medicaid will automatically
be Badger Care providers
BadgerCare benefits are the same as “traditional” WI
Medicaid Program
There are no pre-existing condition exclusions for
BadgerCare.
BadgerCare
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State of Wisconsin Website with latest
information on BadgerCare:
www.dhfs.state.wi.us/badgercare
SOCIAL SECURITY DISABILITY
PROGRGAMS
Income Maintenance Programs
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Two Income Maintenance Programs:
Social Security Disability (SS-D)
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not means tested
Supplemental Security Income (SSI)
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means tested - must meet income and asset
limits to qualify
SSI (continued)
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Some beneficiaries are “dual eligible”
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Income limits apply to SSI eligibility
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receive both Social Security and SSI
excludable income Resource limits apply to SSI eligibility
excludable assets
SSI-E A monthly cash benefit of up to $95.99 is
added to the State SSI payment of each SSI
recipient who meets the program requirements and
is certified for the benefit by a county agency.
http://www.dhfs.state.wi.us/ssi/ssi_e.htm
SSI-E
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SSI recipients whose expenses are greater than the SSI-E
payment level ($758.77 in 2005) and live in one of the
following licensed or certified facilities:
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Foster home for children
Group home for children
Licensed or Certified adult family/foster home
CBRF of 20 beds or less
Certified Residential Care Apartment Complex (RCAC)
or
SSI recipients who live in their own household or another's
household who pay their share of household expenses and
who need at least 40 hours of primary long-term support
services each month.
Health Coverage Programs
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MEDICARE after 24
months
Not means tested
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Medicaid
Eligibility automatic when
qualify for SSI
Means tested
Beneficiaries can have both
Covers more services than
Medicare
SS-D Programs (continued)
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For both disability programs, the adult or
child must meet the disability standards set
by federal law to be found disabled and
qualify for benefits.
SS-D Programs (continued)
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Considerations in a finding of disability for adults:
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Engaged in Substantial Gainful Activity (SGA)
Age and Educational level
Past relevant work experience (past 15 years)
Medical Diagnosis
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Functional limitations caused by condition
Ability to perform other work in the national economy
SSI for Children
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Marked and Severe is a higher level of
severity than previous rules (prior to 1996)
New rules make it more difficult to access the
program, or keep a child in the program.
Five Broad Areas of Functioning
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Cognition/Communication (can now be
separated)
Motor
Social
Personal
Concentration, Persistence or Pace
Disability for Children & Adults
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Advocacy Issues
Need good documentation
Look at combination of impairments
Look at effects of medication or treatment
It is in an applicant’s best interest to appeal a
denial rather than to just keep re-applying
when denied.
PASS PROGRAM
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A plan for achieving self-support (PASS) is a
plan for your future. A plan lets you use your
income or other things you own to help you
reach your work goals. For example, you
could set aside money to go to school to get
specialized training for a job or to start a
business.
http://www.ssa.gov/pubs/11017.html
Pass Program
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With an approved plan, you can set aside money to pay
expenses to reach your work goal. For example, the money you
save can be used for:
Transportation to and from work;
Tuition, books, fees and supplies needed for school or training;
Child care;
Attendant care;
Employment services, such as job coaching and resume
writing;
Supplies to start a business;
Equipment and tools to do the job; or
Uniforms, special clothing and safety equipment.
PASS PROGRAM
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The plan must be in writing, and Social
Security must approve it. To start, contact
your local Social Security office for an
application (Form SSA-545-BK).
If you need help writing your plan your local
Social Security office can either help you or
refer you to a local organization that will help
you.
Disability for Children
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Two booklets from SSA:
CHIDHOOD DISABILITY
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The Supplemental Security Income Program
A Guide for School Professionals
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SSA Publication # 64-049 ICN: 436935
A Guide for Physicians & Other Health
Professionals
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SSA Publication # 64-048 ICN: 436930
Resources
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For more information, visit
www.socialsecurity.gov or call toll-free 1800-772-1213 (for the deaf or hard of
hearing, call our TTY number, 1-800-3250778). They can answer specific questions
and provide information by automated phone
service 24 hours a day
Medicaid for Disabled Adults
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EBD Medicaid through county (deductible is
available)
Medicaid Purchase Plan – Disabled adults
with income up to 250% fpl. Allows disabled
adults to work, and still have access to
Medicaid. Income is calculated based on
both earned and unearned income.
Medicaid Deductible
The Medicaid Deductible is available:
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To individuals/families whose ONLY reason
for denial is excess income;
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(and who are otherwise eligible for the Medicaid
Program)
When they incur or pay medical bills equal to
or greater than the amount of the deductible
they become eligible for Medicaid coverage
The Deductible Period
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A period of six consecutive months;
Begins with the first day of the month of
application, or
Begins with the first day of any of the three
months prior to the month of application.
Meeting the Deductible
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Medical bills for anyone in the family count
toward the Deductible, regardless of when
they were incurred
The Medical bills must be the responsibility
of the family or be paid by the family during
the Deductible period
Meeting the Deductible (continued)
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Medical bills which will be paid by someone else who
is legally liable to pay them cannot be counted.
(Insurance, Medicare)
Medical bills may only be used one time to reach a
deductible.
Large medical bills may be used one portion at a
time to meet many deductible periods
Insurance premiums paid by the family and due
anytime during the deductible period count on the
first day of the period.
EPSDT
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A category of services within Medicaid
Preventive child health (for those under 21)
Section 1905(r)(5) of the Social Security Act
states that any medically necessary service listed
at section 1905(a) be provided to an EPDST
recipient even if that service is not available to
Medicaid recipients in a state’s normal Medicaid
population.
Specific Services
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Services offered include:
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Health and development history
Physical exams
Immunizations
Laboratory tests (particularly blood lead tests)
Vision services
Dental services (not limited to emergency services)
Hearing services
All other necessary health care described in section 1905(a)
to treat or correct any conditions discovered by the
screening services.
Wisconsin Health Insurance Risk
Sharing Plan (HIRSP)
HIRSP-Funding Source
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http://www.dhfs.state.wi.us/hirsp/
HIRSP is funded by a combination of:
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Policyholder premiums
State General Purpose Revenue (GPR)
Assessments on the insurance industry doing
business in Wisconsin
Adjustments to provider payment rates
HIRSP Eligibility
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Under age 65
Automatic eligibility granted disabled people who are
receiving Medicare Part A
People with HIV automatically eligible
People who, due to a physical or mental condition:
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Have been rejected for coverage by one or more health
insurers
HIRSP Eligibility (continued)
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Had coverage substantially reduced
Experienced an increase in premiums by 50% or
more(unless increase was applied to all of the
insurer’s policies)
Have been informed that their premium would be
50% or more greater than the premium for a
standard risk person
HIRSP-Benefits
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Hospital Care
Doctor’s Care
Physical therapy
Ambulance service
Treatment for:
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Mental illness
Alcoholism
Drug abuse
HIRSP-Benefits (continued)
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Prescription drugs
X-Rays
Home health care
Operating room services
Diabetes treatment
Chiropractic treatment
Premium and Deductible
Reduction Program
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Helps low-income policyholders pay HIRSP
premiums
Reduces deductible amounts
Income, as defined by Credit Form Schedule
H, must be below $20,000
Notification will be made within 30 days if
person is eligible for Reduction Program
ABC FOR HEALTH,Inc.
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Visit ABC for Health at www.abcforhealth.org
General and Intake phone line (608)261-6939
Toll free number 1-800-585-4222
THANK YOU FOR COMING
Please feel free to call
with any additional
questions